Informed Consent For General Dental Procedures & Financial Agreement

Stoppelbein & Hardison, DDS

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You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. By consenting to the treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence. It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

GUARANTEE OF PAYMENT, in consideration of dental services extended to this patient, I/we do hereby assume responsibility for the payment of all charges for such services. ALL DEDUCTIBLES AND CO-PAYS ARE DUE AT TIME OF SERVICES ARE RENDERED. IF YOUR CLAIM IS DENIED IN PART OR IN FULL THE PATIENT WILL BE FINANCIALLY RESPONSIBLE FOR ANY REMAINING BALANCE.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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